Provider Demographics
NPI:1457342982
Name:MEDEIROS, JACQUELINE (NP)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:BARUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0366
Mailing Address - Country:US
Mailing Address - Phone:413-733-0010
Mailing Address - Fax:413-930-2108
Practice Address - Street 1:2150 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3566
Practice Address - Country:US
Practice Address - Phone:413-733-0010
Practice Address - Fax:413-930-2108
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119372363LA2200X, 363L00000X
CT002624363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S60781Medicare UPIN
MANP1238Medicare PIN